Inspection on 10/01/07 for Pathways

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pathways 04/12/07

Pathways 09/02/06

Pathways 06/10/05

Pathways 22/02/05

Pathways 24/09/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Pathways 56a Baden Powell Drive Colchester Essex C03 4SR Lead Inspector Tim Thornton-Jones Key Unannounced Inspection 10th January 2007 09:00 Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pathways Address 56a Baden Powell Drive Colchester Essex C03 4SR 01206 761680 01206 862750 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Pelandapatirage Gemunu Susantha Dias Mr Jean Ghislain Domingue Mr Jean Ghislain Domingue Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home accommodates 12 people with learning disabilities who may also have physical disabilities 9th February 2006 Date of last inspection Brief Description of the Service: Pathways is a care home providing personal care and accommodation for 12 individuals with learning disabilities and physical disabilities. It is owned by Mr Dias and Mr Domingue. Mr Domingue is the Registered Manager. Pathways consists of two purpose built detached bungalows, set back from a quiet road in the Shrub End area of Colchester. The home is within easy reach of local shops and a short journey from Colchester town centre, either by public transport or car. The home has its own transport. Well maintained and purpose built, all accommodation is in single rooms, two of which have en suite facilities, there is easy access to all areas of the home and grounds. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The weekly fees for this service were stated to range from £716.00 to £1069.45 per week. The overall care outcomes were good, although in terms of care management, the range and scope of services provided were not always evidenced. Care related documentation would benefit from a full review to ensure that only relevant and helpful information is contained within the daily records. Increased staff involvement in the maintenance of these records and plans would benefit both service users and care staff. Some records were not being adequately maintained although the practice was observed to be sound and care staff spoken with were committed. Service users spoken with were supportive of their home and were confident to communicate. Several relatives’ surveys were received and in the main these were positive and complimentary. One stated that the home was ‘looking shabby’; although on the day of inspection it was evident that some redecoration had taken place. The quality assurance and quality monitoring system needs to be further developed. Overall the service is generally well organised and the standard of practice was good, albeit in the main, resulting from professional intuition rather than as a result of assessed and planned care objectives set within a dynamic plan. There needs to be more attention to detail, particularly in relation to person centred planning and delivery. Although the observed care approach was consultative and staff showed a good understanding of appropriate support staff spoken with were enthusiastic to engage with a wider planning and support role, commensurate with person centred planning. What the service does well: • • • The accommodation is of domestic and homely proportion. The environment was well furnished and clean. Staff were friendly and supportive. DS0000017904.V327942.R01.S.doc Version 5.2 Page 6 Pathways What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. • Service users benefit from the home’s admission procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the care home since the previous inspection and therefore the admissions process has not been used by the home nor was it possible to assess the effectiveness of the service approach as part of ‘case tracking’. The approach that would be used by the home was discussed with senior staff and documentation was viewed. The arrangements were satisfactory should a service user be admitted, although at the time of the inspection no vacancies were available. The approach used is based upon seeking an assessment of the person within their current living situation and the reasons why a move to Pathways would Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 9 be in the person’s best interest and in what way the placement would meet their need. A transitional stay would be arranged and this would be followed by a three month trial period. Each service user is provided with a terms and conditions document or given to a person acting on their behalf if the person lacked capacity. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is adequate. • • • Service users mainly benefit from the care planning arrangements. Service users mainly benefit from support to make decisions about their lives. Service users mainly benefit from the support provided to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A case tracking approach was used for two service users. The care files were comprehensive although they contained a high proportion of material over two years old and the Manager was advised by the Inspector to consider nonactive information to be archived, although all information would need to be Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 11 retained for a period of not less that three years from the date of the document. Several of the assessment and care planning tools being used were not dated and it was therefore difficult to ascertain the relevance of the data. Some known care characteristics and known risks relating to service users were not subject to a current risk assessment and a further review would benefit care practice. The structure of the care plan presented as logical in process and was set out clearly. The plans sampled showed that the care planning process begins with a ‘priority of needs’ statement followed by an individual programme plan (IPP), which lists the ‘need/problem identified’ and ‘objectives’. The most recent evaluation date for the first sample was November 2005 and was therefore in need of review. Flowing from the IPP are individual ‘Implementation Guidelines’. These are drawn together based upon each care objective and provides for good continuity of planning. The documents provide clearer guidance to care staff to deliver the intended care outcome. The guidelines, in the sample, were last reviewed July 2006 and as this was about six months, would benefit from more frequent review. The documentation seen did not support the practice of consultation and participation of the service user within the review process and did not reflect the essential principle of a ‘person centred’ approach. Each service user has a daily diary showing the day to day activities being undertaken. This is a helpful document although there were limited links with the plan of care and decision making process. Both sampled care plans indicated that the supporting agency (Local Authority) had reviewed the placement within the preceding 12 month period, and although there was some indication that the service user was present at the time of the review, there was not sufficient evidence to demonstrate that the service user took an active and participative role. In circumstances where service users are unable or unwilling to contribute to the review and planning process, this needs to be properly shown within the plan and the reasons why. Healthcare arrangements were variable in terms of the sampled seen. One sample indicated that two appointments had been attended to an eye specialist during 2006. Confirmation was obtained that the individual had been to hospital to have the removal of cataracts, although the information and follow up were not clearly expressed within the plan of care. By contrast the second care plan sample seen indicated that the primary healthcare recording was more comprehensive for Optician, Dentist and Hearing, although visits to the GP, which it was understood was relatively frequent throughout the year for the person subject to the case tracking, due to a chronic medical condition, were not well recorded. It became apparent through discussion with service users and staff that service users do attend planned day centre activities, further education and a Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 12 range of community based activities, although this aspect of service users life is not well recorded within the care plan. Whilst the structure of care planning is sound, the care plans require some review to ensure that risk assessment practice is up to date, decisions are adequately reviewed and all relevant aspects of the persons life are included and monitored within the care plan, including healthcare. The plans would benefit from ensuing that service users contribution to their plan is demonstrated more comprehensively. In discussing the service with staff it was apparent that service users are well supported and that a good deal of understanding shapes the way carers deliver the support. The communication and quality of interaction between carers and service users was positive and genuine relationships were clearly demonstrated. Carers have a high degree of professional intuition and it is this quality that appears to chiefly maintain the positive care outcomes for service users rather than the use of the existing care planning tools. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. • • • • • Service users, who are able to, benefit from educational and training opportunities. Service users do not all benefit from participation within the wider community in accordance with assessed needs and individual plans. Service users benefit from the arrangements to maintain links with family. Service users benefit from the service approach to rights and responsibilities. Service users mainly benefit from the service arrangements for meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 14 At the time of the inspection it was apparent that service users were benefiting from a variety of social opportunities. These were expressed by service users and by observation, for example service users went out with care staff. The service has it’s own transport and this is used to ensure good access to community resources. The funding arrangements for the transport were not examined on this occasion. No service users accommodated have the capacity to undertake employment or any occupational work substitute, although some service users are involved in leisure/social based schemes suitable for people who are learning disabled. Service users also have opportune ities to participate in activities that are not specifically for disabled participants by using various community resources such as swimming and bowling. Various photographs were displayed showing activities and parties such as Halloween and a trip to the Zoo, although disappointingly these were from 2005 and 2004 respectively. Based upon the ‘case tracked’ sample, a period of time in which the daily diaries were reviewed between 1st and 9th January 2007. For one service user it was clear that the person had attended a day centre on one day and had been engaged in indoor activities. For the second person there was no activity recorded other than entries saying ‘spent time in the bungalow’. Whilst it was observed that staff did engage with this particular service user, no structured activity was observed or evident within the plan. The care plan and social/emotional support for this person requires review. Family links are maintained and encouraged. Reviews of service users do involve relatives and the plans indicate that families have been consulted with at appropriate times. The Manager will need to ensure that families are consulted appropriately since it would be expected that service users are consulted initially, and then families, should there be concern about the persons capacity. This will contribute to the service objectives purporting to maintain a ‘person centred’ service. The environment within the dwelling is relaxed and informal. Both service users and staff were ‘at home’ and a positive atmosphere was apparent. The ethos of the service supports the view that rules are kept to a minimum and service users are respected. The privacy and dignity of service users was maintained in the daily operation of the home (notwithstanding comments made within the report regarding curtains/blinds). Menu planning is flexible and mainly well recorded although during the week of the inspection the breakfast and lunch had not been recorded for the sample group. Service user spoken with expressed satisfaction with the lunchtime meal. carers prepare, cook and serve meals as part of their duties. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 15 Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 to 20. Quality in this outcome area is good. • • • Service users benefit from the way in which personal support is provided. Service users do not fully benefit from the healthcare monitoring arrangements. Service users benefit from the homes arrangements to support service users with their prescribed medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Based upon two care plans sampled, the healthcare arrangements were in need of improved monitoring. Whilst service users do have access to healthcare professionals such as optician, dentist and GP, the arrangements could be further developed and improved. For one sample, the service user has a range of presenting healthcare needs described by staff. The care plan did contain information in a chronological format regarding attending GP Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 17 appointments but these were included within a general reporting format to the rear of the plan. One carer who was asked about GP information could not find the relevant data in the plan, although the Manager was able to locate it. This method does not support active and easily accessed monitoring and would benefit from re-organisation. Regarding healthcare and care planning recording and monitoring, there was limited evidence that carers specifically contribute to the monitoring process. A key worker approach is in operation and care staff who were asked about the way this worked, were able to respond adequately, although all involvement tended to fall short of regular and specific contribution to plans and other recording tools. These tended to be undertaken by the Manager or Deputy. An improved continuity of approach would be developed further if key workers were integral to the assessment, healthcare planning monitoring and review of the care process. Care staff spoken with demonstrated a good commitment to care standards and throughout the inspection the interaction between all those living and working at Pathways was positive, friendly and relaxed. The quality of the interaction reinforced a dignified and respectful approach. The arrangements for prescribed medicines held in safe custody for service users were examined in bungalow 2. The security arrangements were satisfactory and administration of medicines was good in relation to the sample seen. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. • Service users benefit from the homes arrangements for the investigation of complaints and the safeguarding practices associated with the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint procedure; a version is available for service users and is located within the Service Users Guide. A copy is located within the service user file. The complaint policy and procedure requires amendment to clarify that the CSCI does not investigate complaints although does investigate departures from the regulatory requirements. The Manager confirmed that no complaints or safeguarding adult matters have been investigated during the period since the previous inspection. CSCI have not received a formal complaint, allegation or safeguarding adults issue during the same period. The homes arrangements for safeguarding adults were satisfactory. The service has a set of guidance documents produced by Essex County Council together with a training pack/DVD and workbooks for staff, although this has not yet commenced. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 19 Staff have received some training in relation to safeguarding adults procedures and practice. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 28 and 30. Quality in this outcome area is good. • • • Service users do not fully benefit from the service arrangements to safeguard privacy and dignity. Service users benefit from the availability of shared space to supplement individual rooms. Service users benefit from a clean and adequately furnished environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service consists of two bungalows each accommodating six persons. All of the bedrooms are for single occupation. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 21 The home does not offer short stay or respite care services. Each dwelling is self contained and each has a staff office. There are no sleep-in facilities for staff as the service maintains waking night care support. For this inspection, bungalow two was the focus of inspection although some of the required records were held for both dwellings in Bungalow one, and during this part of the inspection had opportunity to speak with both service users and staff who commented upon the environment in a positive way. In a tour of the building all of the communal rooms were visited and also most of the bedrooms. All of the rooms seen were well maintained and decorated. The bedrooms were personalised and reflected the gender and preferences of the occupants. There were no obvious safety hazards noted and there were no unpleasant odours. Overall the rooms were bright and cheerful, however, in the dining room and one bathroom no curtains or blinds were apparent. It was clear that the fixings were in place and the Inspector was advised that one service user, as a result of challenging behaviour, regularly pulled the curtain/blind down. The Inspector and staff discussed ways in which the home might approach this problem. The short term concern was for the privacy and dignity of persons using the bathroom, since whilst the room had obscured glass, it would not be possible to be fully private without a curtain or blind. The kitchen area was of domestic size and style, clean and well maintained. The laundry area is also of domestic proportion with adequate cleaning and drying equipment. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. • • • • • Service users do not yet fully benefit from the support of competent and qualified staff. Service users benefit from the number of care staff deployed to meet their needs. Service users do not yet fully benefit from the service recruitment and induction procedures. Service users do not yet benefit from the arrangements for the training of staff for all the skills and knowledge required to deliver a satisfactory service. Service users do not yet fully benefit from the service approach to supervising and supporting staff at adequate intervals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 23 Some training issues were noted. One staff member, as part of their duties undertakes administration of prescribed medicines and has not received training. Whilst not making judgement upon presumed staff competence, no carer should be undertaking this task without appropriate and suitable training. A total of 20 care staff are stated to be employed across both dwellings. Of these 7 have attained an NVQ qualification to at least level 2. The Manager advised that a further 5 carers are working toward NVQ2. This ratio does not yet meet with the 50 level stated within National Minimum Standards. Staff have attended various care related courses although the National Minimum Standards for adult care homes of each staff member having an individual training and development profile has not yet been achieved, however, the manager showed the inspector a blank, proposed version. When introduced, this document will reflect good practice. Documentation was in place to show that the service had considered the training needs of staff as a whole. The service calculates the staff/service user ratio using a method recommended by the Department of Health (Residential Forum) and the most recent assessment indicated the requirement of 486.47 hours per week. The staff roster for week ending 7th January 2007 indicated that across the two dwellings a total of 707 hours were deployed. The relative ‘surplus’ of 220.53 is required because of the separate self contained nature of the service being provided in two dwellings, and that care staff also undertake all support tasks such as cooking, cleaning and laundry. It is important to note that evidence was not available to show that all staff had attended a food hygiene certificated training within the last three years. The Manager undertakes 25 hours per week in a supernumerary capacity. Recruitment practice was, overall good, although it was found that one staff member did not have a Criminal Record Bureau (CRB) certificate. The Manager stated that a POVA first check had been completed and was satisfactory, although there was no presenting evidence of the check. The file did not evidence that the individual was receiving supervision by a named person as is required by regulation. Staff were receiving supervision although the frequency varied across the sample seen. Not all staff had received 6 supervision sessions within a 12 month period, however, the supervisory agreements were in place and an induction approach was being followed, however, for new staff this was not specifically the 12 week Skills for Care programme as required. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 41 and 42. Quality in this outcome area is adequate. • • • • Service users benefit from the service being managed by an experienced and trained person. Service users do not benefit from the service quality assurance and monitoring system. Service users do not yet fully benefit from the service record keeping. Service users benefit from the service arrangements for health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is also the Registered Person as part of a Partnership. Mr Domingue has qualified previously as a nurse (RNMH) specific to the care of Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 25 people with a learning Disability and has also attained a management qualification (CIM). In addition Mr Domingue has also undertaken some management units at NVQ level 4. Overall the management of the service is sound although as a result of this key inspection, the findings indicate that some key National Minimum Standards are not being met. The quality assurance and monitoring system requires further work. The questionnaires used for the purpose of seeking views of service users were not fit for purpose on the basis of the question construction and the use of language. The questionnaires will need to be produced in an easy read format that service users are able to use with minimum support. For those service users who require help to complete the questionnaires, it is advised to have supplementary information available to identify how the responses were obtained to ensure reliability and validity of the information used to assess the quality outcome. Some records were sampled and were variable in meeting regulatory requirements. Those meeting requirements included staff roster, accident and missing person’s procedure, aspects of the recruitment requirements, duty roster, service charges, various heath and safety records, record of visitors and reports of the conduct of the home by the Registered Person. Those in need of improvement include care plans, some records associated with employees and record of food served. The service maintains records and procedures in relation to health and safety matters, this included the following checks. The last fire alarm test was recorded as 5th January 2007. The last fire evacuation drill recorded as having taken place on 4th December 2006. Fire extinguishers and associated equipment was recorded as having been checked by an engineer on 13th December 2007. The emergency lighting system and portable appliance assessment was recorded as checked by an engineer on 10th January 2007. The gas installation safety check was recorded as having been undertaken on 11th January 2007. The home maintains records in accordance with Care of Substances Hazardous to Health requirements. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X 2 X 3 Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 17(2) Requirement The Registered Person must ensure that staff have all of the competencies required to meet the needs of service users accommodated. This is a repeat requirement to have been achieved previously by 30.06.06. The Registered Person must ensure that a suitable staff development and training programme is in place. This is a repeat requirement. This is a repeat requirement to have been achieved previously by 30.03.06. The Registered Person must ensure that staff are adequately supervised. This is a repeat requirement to have been achieved previously by 30.04.06. The Registered Person must ensure that all records required by Regulation are appropriately maintained. This is a repeat requirement to have been achieved previously by 30.03.06. The Registered Person must DS0000017904.V327942.R01.S.doc Timescale for action 31/03/07 2. YA35 18(1)(c) 31/03/07 3. YA36 18(2) 31/03/07 4. YA41 17(2) 31/03/07 5 Pathways YA6 15(2)(b) 31/03/07 Page 28 Version 5.2 6 YA7 YA9 7 YA13 8 YA24 9 YA39 ensure that care plans describe how current and changing needs and aspirations of service users are to be met and to keep them up to date by reviewing at least every six months or more frequently as required. 14(2)(a)(b) The Registered Person must ensure that assessment of service users needs is kept under review and revised at a time when it is necessary to do so having regard to any change in circumstances. 15(2)(b) The Registered Person must 14(2)(a)(b) ensure that all service users have opportunity to become part of, and participate in, the local community in accordance with assessed needs. 12(4)(a) The registered Person must ensure that the home is conducted in a manner that protects the dignity and privacy of service users. This refers specifically to the use of curtains or blinds at windows. 24(2)(a to The Registered Person must c) develop a system for evaluating 24(3 to 5) the quality of the services provided at the care home. 31/03/07 31/03/07 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations The Registered Person is recommended to undertake an assessment of the required hours for staff to undertake non-care related tasks. The Registered Person is recommended to review the way in which healthcare records and access to these by staff DS0000017904.V327942.R01.S.doc Version 5.2 Page 29 2. YA19 Pathways are organised to improve communication and planning. Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pathways DS0000017904.V327942.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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